Differences in Maternal Mortality Among
Black and White Women -- United States, 1990

The risk for maternal mortality has consistently been higher
among black women than white women. The 1990 national health
objective of reducing maternal mortality to no more than five
deaths per 100,000 live births for any racial/ethnic group was
nearly achieved for white women, for whom the maternal mortality
ratio * was 5.7 in 1990 (1); for black women, however, the ratio
was
18.6. The year 2000 national health objectives include reducing the
overall maternal mortality ratio to no more than 3.3 deaths per
100,000 live births and to no more than five for blacks (objective
14.3) (2). This report summarizes race-specific differences in
maternal mortality among black and white women for 1990 and
compares these with trends in mortality from 1940-1990.

Maternal mortality ratios were calculated at 10-year intervals
from 1940 to 1990 using data contained on death certificates filed
in state vital statistics offices and compiled by CDC in a national
database (3,4). Maternal deaths were defined as those for which a
maternal condition was designated as the underlying cause of death,
as recorded on the death certificate by the attending physician,
medical examiner, or coroner. ** This report compares maternal
mortality only for black and white women because data for other
racial/ethnic groups were not available for all years; data for
Hispanic women are included in the totals for both blacks and
whites.

In 1990, the overall maternal mortality ratio was 8.0 deaths
per 100,000 live births, a 98% decline from 363.9 in 1940. From
1940 to 1990, race-specific ratios declined substantially, from
319.8 to 5.7 for white women and from 781.7 to 18.6 for black
women. Although the percentage decline was similar for black women
and white women (97.6% and 98.2%, respectively), the ratios for
black women were consistently two to four times higher than those
for white women. For example, compared with that for white women,
the maternal mortality ratio for black women was 2.4 times greater
in 1940, 3.6 times greater in 1950, 4.1 times greater in 1960, 3.9
times greater in 1970, 3.4 times greater in 1980, and 3.3 times
greater in 1990 (Figure_1, page 13).

From 1960 through 1990 (years for which more detailed data
were available), the maternal mortality ratio was higher for black
women in all age groups and for each of the major causes of death.
The black-white differential was greatest for pregnancies that did
not end in a live birth, such as ectopic pregnancy, spontaneous
abortion, induced abortion, and gestational trophoblastic
disease. ***

Editorial Note

Editorial Note: Despite overall improved maternal survival during
1940-1990, black women were more than three times more likely than
white women to die from complications of pregnancy, childbirth, and
the puerperium. Although the reasons for this disparity are
unclear, possible explanations include differences in
pregnancy-related morbidity, access to and use of health-care
services, and content and quality of care.

Maternal hospitalization, except when associated with
delivery, can serve as a marker for severe maternal morbidity. For
example, during 1987-1988, a study of pregnancy-related
hospitalizations indicated the ratio for black women was 1.4 times
that for white women (6); during the same period, the black-white
maternal mortality ratio was 3.1. However, in a study of women in
the military -- who have unrestricted access to prenatal care --
there
was virtually no difference between black and white women in the
overall prevalence of antenatal hospitalization and in the
indications for hospitalization (7).

Early entry into prenatal care (i.e., during the first
trimester) -- one indicator of access to and use of
pregnancy-related
health care -- has been assessed for women whose pregnancies ended
in
a live birth. During 1980-1990, although 76% of all mothers
received early prenatal care, the percentage of black women who did
not receive early prenatal care was nearly twice that for white
women (8). In 1990, 39.4% of black mothers did not receive early
prenatal care, compared with 20.8% of white mothers. Once women
enter prenatal care, studies indicate differences between black and
white women in the advice given to them and use of technology
(9,10).

Data describing access to pregnancy-related health care other
than prenatal care (e.g., gynecologic services) or the content and
quality of health care once women obtain these services are
limited. Narrowing discrepancies in maternal mortality between
black and white women will require evaluating and addressing
race-specific differences in morbidity and in access to and use and
content of pregnancy-related care. Addressing discrepancies in
maternal mortality also may improve maternal morbidity and infant
survival.

References

Public Health Service. Promoting health/preventing disease:
objectives for the nation. Washington, DC: US Department of Health
and Human Services, Public Health Service, 1980.

NCHS. Vital statistics of the United States, for years 1939-
1991. Vol I-natality. Hyattsville, Maryland: US Department of
Health and Human Services, Public Health Service, CDC.

NCHS. Vital statistics of the United States, for years 1939-
1991. Vol II-mortality, part A. Hyattsville, Maryland: US
Department of Health and Human Services, Public Health Service,
CDC.

NCHS. Estimates of selected comparability ratios based on dual
coding of 1976 death certificates by the eighth and ninth revisions
of the International Classification of Diseases. Hyattsville,
Maryland: US Department of Health and Human Services, Public Health
Service, CDC, 1980. (Monthly vital statistics report; vol 28, no.
11, suppl).

* The maternal mortality ratio is the number of maternal deaths per
100,000 live births. CDC's National Center for Health Statistics
(NCHS) uses the term maternal mortality rate as required by the
World Health Organization. In this report, the term "ratio" is used
because the numerator includes some maternal deaths that were not
related to live births, and thus were not included in the
denominator. For this analysis, 3 years of data were combined to
calculate maternal mortality ratios to promote statistical
reliability and stability in the estimates. For example, 1990
ratios are based on data from 1989 through 1991. In addition,
beginning with the 1989 data year, NCHS began using race of mother
instead of race of child to tabulate live birth and fetal death
data by race. In this analysis, race for live births is tabulated
by the race of the child for maternal mortality to maintain
comparability of ratios.

** An underlying cause of death is defined by the International
Classification of Diseases, Ninth Revision (ICD-9), as "a) the
disease or injury which initiated the train of morbid events
leading directly to death, or b) the circumstances of the accident
or violence which produced the fatal injury.
provided the first formal definition of maternal mortality,
defining maternal death as the death of a woman while pregnant or
within 42 days of termination of pregnancy. This definition
differed from that used previously by NCHS, which included deaths
up to 1 year after termination of pregnancy. However, the change
from the 1-year limit used in the eighth revision to the 42-day
limit used in the ninth revision did not greatly affect the
comparability of maternal mortality statistics (4).

*** The ICD code is revised approximately every 10 years. In the
ninth revision, ectopic pregnancy (ICDA code 631) was transferred
from complications of pregnancy (ICDA codes 630 -- 634) to
pregnancy
with abortive outcomes (ICD codes 630 -- 638) (5). In this report,
maternal deaths from ectopic pregnancy are included with abortive
outcomes for all time periods.

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